Current Concepts in Thoracic Drainage Systems Edward R. Munnell, M.D., a n d E. Kent Thomas, M.D. ABSTRACT Thoracic drainage systems are currently marketed in many varieties, resulting in significant cost and complicating patient management. Realistic needs have been identified from a survey of thoracic surgeons. These are: (1) clear plastic chest catheters with multiple drainage holes in sizes 28,32, and 36F for adults and 16, 20, and 24F for infants and children; (2) serrated plastic connectors that can be sized at operation; (3) connecting tubes of clear plastic 6 feet long with a diameter of ?4 inch; (4) a single graduated volumecollecting bottle of 1- to 2-liter capacity that can be emptied and marked, with a separate waterseal component and an associated manometer; and ( 5 ) a highflow vacuum source. A drainage system with these characteristics should be safe, effective, simple, and less costly.

P

ostoperative chest drainage has been predicated on the primary need to remove gas and liquids and to restore normal cardiorespiratory function. T h e mechanics of thoracic drainage systems devised to meet these needs are based on known physiological and physical principles. But during the past fifteen years, changing surgical techniques, new materials and manufacturing technology, and tangential influences have introduced a number of basic design modifications. As a result, current drainage systems are complex, multipartite, multipackaged, of numerous types, and expensive, causing difficulties in management and increased cost of medical care. Because of the morass of chest drainage systems, it seemed desirable and timely to see if these systems were meeting the needs of experienced thoracic surgeons. In addition, we hoped that this study might result in the design of a safe, effective, simple, and unencumbering drainage system of reasonable cost.

Method A questionnaire was formulated and distributed to the 442 members of the Southern Thoracic Surgical Association and to 48 thoracic surgeons outside the Association. T h e query consisted of 25 main questions divided into five principal categories: (1) chest tubes o r thoracic catheters; (2) chest tube connectors; (3) drainage tube systems; (4) collecting systems; and (5) vacuum o r suction methods. Returned questionnaires were edited as necessary for data retrieval, and personal comments were identified and collected. All answers were tabulated by data processing and applicable percentages obtained. From the Departments of Surgery, Oklahoma City Clinic and the University of Oklahoma College of Medicine, Oklahoma City, Okla. Survey supported in part by Chesebrough-Ponds, Inc. Presented at the Twenty-first Annual Meeting of the Southern Thoracic Surgical Association, Williamsburg, Va., Nov. 7-9, 1974. Address reprint requests to Dr. Munnell, 301 N.W. 12th St., Oklahoma City, Okla. 73103. VOL. 19, NO. 3, MARCH, 1975

26 1

MUNNELL AND THOMAS 100

-

90W

y 2 In k

80

-

70-

6050-

+ 40

2

-

33.9 -

30-

K

20

Y

L

lo 0

-

-

,

2.4

.

2.1

22.8

4.4

Results Three hundred twenty-eight (67%)of those queried responded. A total of 95 questions were tabulated. For many questions, thoracic surgery was categorized into routine thoracotomy, open-heart procedure, pneumonectomy, segmental resection or lobectomy, and esophageal or diaphragmatic operation. Consequently, in addition to answers on chest drainage, considerable information was obtained concerning management of specifictypes of thoracic surgical problems. Chest Tubes (Thoracic Catheters). Tube sizes routinely used in adult thoracic surgery are shown in Figure 1. The most popular are 28,32, and 36F. In pediatric thoracic surgery a range of sizes - from 6 to 26F - is utilized; sizes 16,20, and 24F are slightly favored, totaling 45.4%of the answers. As shown in Figure 2, for most thoracic operations one or two chest tubes are employed, but 69% of the respondents do not use a drainage tube in pneumonectomy. As might be expected, a majority (87.5%)use tubes with multiple fenestrations (three or more) at the intrathoracic end. Chest Tube Connectors. Of the varieties of chest tube connectors available, 72% of the surgeons prefer connectors with serrations because of their greater holding ability. Only 28% favor a smooth connector for ease of handling. When more than one chest tube is used, the tubes may be attached to independent drainage units or may share a single collecting unit with either a Y -connector or independent drainage tubes. T w o collecting bottles are the choice of 43.9% of the respondents, while 30.3% favor use of the Y-connector; 24.8%use independent 100 90 W

z

u)

2

u)

8

tomv PneumMlectmv

80

70 60

FIG. 2. Number of chest tubes used in routine thoracotomy, various types of pulmonary resection, and cardiac, esophageal, or diaphragmatic operations. The management of pzeumonectomy differs from other thoracic procedures. Numbers are percentages of total answers for each group.

50 40

K

30 20 10

0 0

262

1

2

3

4

THE ANNALS OF THORACIC SURGERY

Thoracic Drainage Systems

-

100

90-

90

80

80

100

p 2 Y

v)

$ I-

z

0 K

g

-

70

70-

-

6050 40 30 20 10

0

49.4

-

-

-

-

60 50 40

26.5

6.3 -

18.0

30 20

-

-

-

53.2 -

-

10 0 -

29.0 3.5

9.5

VOL. 19, NO. 3, MARCH, 1975

263

MUNNELL AND THOMAS 100

90 W

80

v)

$

--

70-

v)

g

60

$ $

50 40 30 20

8

-

10 -

m

42.7 28.5 17.2 11.1

0

1

0.5

FIG. 6. Postoperative drainage (in liters)from all types of thoracic operations. Numbers are percentages of 1,158 answers.

100 90 W

m

$ v)

w LL:

z w K P

80

70 60

50 40 30 20

264

11.7

10 0

FIG. 5. Frequency and methods of adding negative pressure (vacuum) to a drainage system; 71 % use suction at some time

0- 1

1-2

0.9

1.0

0.4

2-3

3-4

Over 4

THE ANNALS OF THORACIC SURGERY

Thoracic Drainage Systems TABLE 1. EVALUATION OF SPECIFIC FEATURES OF THORACIC DRAINAGE SYSTEMS'

Features Can be emptied Can be emptied & reused Markable (date & time) A graduated volume Sampling ports Stoppers or screwcaps (to vary design) Metering of air leaks

Necessary

Optional

Unnecessary

63.2 46.8 75.5 59.1 11.4

24.0 35.3 20.8 30.3 31.3

12.4 18.0 3.9 10.8 57.7

24.4 18.9

40.0 37.0

35.8 44.3

'Numbers are percentages of total response.

thoracic operations revealed that 36% use gravity (hydrostatic pressure) as the lowest form of vacuum. If additional vacuum is used, the least amount is 10 cm HzO (41%). Opinion has differed considerably concerning the highest vacuum to use following thoracotomy. Thirty-three percent occasionally use 30 cm HzO as the highest vacuum, but the data suggest that over 40 cm HzO is sometimes needed (23% of answers), primarily in segmental pulmonary resection. While the noise level of a vacuum system motor or the air vent bubbling is bothersome to some surgeons, the respondents are almost equally divided on the question. Fifty-two percent indicate that the noise is bothersome and 48%that it is not. Table 3 shows the opinions of the responsible surgeons on who should manage a thoracic drainage system. The consensus is that all members of the therapeutic team -surgeon, house staff, students, and nursing staff -should be involved.

Comment Thoracic drainage systems are far removed from the tube, cork, stopper, and vessel that made up the original waterseal system conceived by Hewett in 1876 [41. While there has been some agreement on the purpose of chest drainage and on TABLE 2. UTILIZATION OF VARIOUS SOURCES OF VACUUM OR SUCTION FOR THORACIC DRAINAGE SYSTEMS'

Type of Vacuum or Suction

Percent Favoring

High-volume system Wall suction (vacuum) Emerson or similar system

40.7 41.5

82.2

Low-volume system Gomco or similar system Stedman system

11.5 2.6

14.1 3.7

Other 'Numbers are percentages of total response.

VOL.

19, NO. 3, MARCH, 1975

265

MUNNELL AND THOMAS TABLE 3. RESPONSE T O THE QUESTION: WHO SHOULD MANAGE THORACIC DRAINAGE SYSTEMS?’

Personnel Surgeon only House staff Medical students Nursing staff All of the above

Percent Favoring 13.0 14.2 30.8 19.3 22.8

‘Numbers are percentages of total response.

physiological norms or alterations induced by thoracotomy [2,5,8], the methods of managing a postoperative pleural space continue to vary. The chest tube has evolved from a rubber colon tube or right-angled nephrostomy tube to plastic radiopaque tubes in innumerable sizes with different numbers of apertures. At least two dozen sizes are available. Straight o r Y-connectors with smooth or serrated ends made of several plastic materials or glass can be stocked in at least a dozen and a half varieties. Disagreement arises on the length, diameter, and material ofthe tube connecting the chest catheter with a collecting system [ 1-31. The classic three-bottle collecting system has been variously described as combinations of collecting bottles, waterseal bottles, manometer bottles, and trap bottles [5, 7, 81. System designs are now basically of three types: 1. Homemade combinations of bottles, graduated cylinders, stoppers, and rubber or plastic tubing. 2. Plastic systems (e.g., Pleur-evac) which, in spite of several attributes, are costly, lack needed components or design, and have some features of doubtful utility. 3. Glass bottle collecting systems (e.g., Clinical Products) which are relatively inexpensive but have too many varieties (11) and are multipackaged. These too meet some needs but, because of other deficiencies, do not fulfill the requirements of an ideal drainage system. Roe [6], Batchelder and Morris [l], and Enerson and McIntyre [2] have clarified the proper amount of negative pressure and the volume per minute flow of air that should be used when vacuum is needed. For vacuum, a hospital may offer low-flow,low-negative-pressuresystems of the Stedman, Gomco Thermotic, or Thorovac type and may supply more satisfactory high-volume, mobile pleural drainage pumps in the form of either Emerson or Sorensen units or by built-in wall suction. The expense of drainage systems is considerable and varied. The simplest waterseal drainage may cost from $12 to as much as $42. A two-chest-tube, “three-bottle” concept may cost from $20 to as much as $83. Difference in price depends upon the combinations of chest tubes, connectors, and kind of collecting

266

THE ANNALS OF THORACIC SURGERY

Thoracic Drainage Systems system. In addition, the need for a portable vacuum source is an extra daily cost in most hospitals. Chest drainage is expensive, complex, somewhat confusing, and to a degree hazardous (on account of breakage or leakage). This situation has come about through technological changes, new concepts of management, use of new materials, and manufacturers responding to multitudinous requests (tangential influences) for this or that modification. Improvement is possible, however. In numbers of answers and cross-section of practice, this survey is a valid sampling of the needs of thoracic surgeons. The practices of these Board-certified surgeons encompass the entire scope of today’s thoracic surgery. In footnotes to the questionnaire, many respondents express a desire for a system that is safe, simple, effective, and less expensive. One surgeon* summarizes the feeling: on the chest drainage systems of his patients is a sign, “F G S K Y H 0 T B” - meaning, “For God’s sake, keep your hands off the bottle!” Some well-grounded requirements for thoracic drainage can be concluded: 1. Thoracic catheters should be of clear plastic with radiopaque markings and multiple drain holes. For adults primarily sizes 28, 32, and 36F are needed, and infants and children require catheters with the same characteristicsin sizes 16, 20, and 24F. 2. A serrated plastic connector is necessary for attaching the chest tube. It should be plastic so that it can be cut to fit the chest tube at operation and one limb of the Y occluded. Thus, it could be used as either a Y- or a straight connector. This would eliminate the problem of multiple varieties of connectors and packaging problems. 3. Clear plastic connecting tubes ‘/2 inch in diameter and 6 feet long, equipped with rubber or elastic plastic banding and safety pins for attachment to a patient’s bed, are needed. For pediatric patients a shorter tube of ‘/4 inch diameter would be best. Since most surgeons use a surgical instrument for tube clamping, a similar device should be furnished with the system. 4. A single-bottle collecting system with a capacity of 1 to 2 liters should be part of the system. With this, the system should have a separate waterseal component, should be capable of being emptied and used again, should be markable with dates and time, and should have a graduated volume (smaller graduations during the first several hundred milliliters of drainage and then greater increments for volumes of more than 500 ml). The device should have an associated simple adjustable manometer. 5. A vacuum source, when needed, should be capable of delivering vacuums readily changing from 0 to 60 cm HzO with an air-flow volume of 15 to 20 liters per minute. This can be achieved by hospital wall suction, but a simpler portable vacuum system with these characteristics should be developed - one of less cost and complexity than today’s portable vacuum systems. *J. E. Dailey, personal communication, 1974.

VOL. 19, NO. 3, MARCH, 1975

267

MUNNELL AND T H O M A S Finally, the system should be so straightforward in design that any member of a therapeutic team could comprehend and manage thoracic drainage. Now that the essential requirements for chest drainage have been identified, it is time for a system to be developed that is less costly and more convenient, effective, safe, and simple; in other words, one that meets the needs.

References 1.

2. 3. 4. 5. 6. 7.

8.

268

Batchelder, T., and Morris, K. A. Critical factors in determining adequate pleural drainage in both the operated and unoperated chest. Am Surg 28:296, 1962. Enerson, D. M., and McIntyre, J. A comparative study of the physiology and physics of pleural drainage systems.J Thoruc Cardiovusc Surg 52:40, 1966. Evaluation: Pleural drainage pumps. Health Devices 1 :34, 197 1. Hewett, F. C. Thoracentesis: T h e plan of continuous aspiration. Br Med J 1:317, 1876. Perkins, R. Early management of the pleural space following partial pulmonary resection. Am Surg 23:555, 1957. Roe, B. B. Physiologic principles of drainage of the pleural space. Am J S u r g 96:246, 1958. Sweet, R. H. Thoracic Surgery. Philadelphia: Saunders, 1950. von Hippel, A. Chest tubes and chest bottles. Springfield, 111.: Thomas, 1970.

THE ANNALS OF THORACIC SURGERY

Current concepts in thoracic drainage systems.

Thoracic drainage systems are currently marketed in many varieties, resulting in significant cost and complicating patient management. Realistic needs...
791KB Sizes 0 Downloads 0 Views